Ureteral Fistula Research Articles

The “Pumping Probe Technique” and complete sealing stent – a new simple method for the detection and treatment of ureteric fistulae

The “Pumping Probe Technique” and complete sealing stent – a new simple method for the detection and treatment of ureteric fistulae

The changing face of obstetric fistula surgery in Ethiopia.

ObjectiveTo examine the incidence and type of obstetric fistula presenting to Hamlin Fistula Ethiopia over a 4-year period.Study designThis is a 4-year retrospective survey of obstetric fistula treated at three Hamlin Fistula Hospitals in Ethiopia, where approximately half of all women in the country are treated. The operation logbook was reviewed to identify all new cases of obstetric fistula presenting from 2011 to 2015. New cases of urinary fistula were classified by fistula type (high or low), age, and parity of the woman.ResultsIn total, 2,593 new cases of urinary fistulae were identified in the study period. The number of new cases fell by 20% per year over the 4 years (P<0.001). A total of 1,845 cases (71.1%) were low (ischemic) fistulae, and 804 cases (43.6%) of these had an extreme form of low circumferential fistula. A total of 638 (24.6%) women had a high bladder fistula, which predominantly occurs following surgery, specifically cesarean section or emergency hysterectomy, and 110 (4.2%) women had a ureteric fistula. The incidence of high fistulae increased over the study period from 26.9% to 36.2% (P<0.001). A greater proportion of multiparous women had a high bladder fistula (70.3%) compared with primigravid women (29.7%) (P<0.001). Conversely, a greater proportion of primiparous women experienced a low circumferential fistulae (68.6%) compared with multiparous women (31.4%) (P<0.001).ConclusionThere appears to be a decline in the number of Ethiopian women being treated for new obstetric urinary fistulae. However, the type of fistula being presented for treatment is changing, with a rise in high fistulae that very likely occurred following cesarean section and a decline in the classic low fistulae that arise following obstructed childbirth.

Complicaciones urológicas del tratamiento quirúrgico del carcinoma del cuello uterino. Terapéutica y profilaxis

El especialista siempre ha temido a las complicaciones urológicas a causa de la cirugía radical del carcinoma del cuello uterino. La forma clásico; de dichas complicaciones es la fístula necrótica del uréter. Durante los primeros años ocurría en más de 10% de los casos y aún hoy día encontramos tales cifras en manos de algunos cirujanos; aunque en su mayoría ha disminuido. A esta forma clásica se adhieren hoy otras cuyo origen es la linfadenectomía.

Postoperative ureteral leak treated using a silicone-covered nitinol stent.

Ureteral fistula is a serious complication of abdomino-pelvic surgeries, often resulting in poor outcomes owing to lack of proper treatment. We report the case of a 49-year-old woman who underwent placement of a silicone-covered ureteral occlusion stent in her right ureter for the management of ureteral leakage after pelvic surgery. A ureterogram obtained 18 months following the stent placement confirmed that there was no stent migration or additional urine leakage. We propose that the silicone-covered ureteral occlusion stent is practical, fast, and safe for the management of ureteral leakage.

Histological evaluation of ureteral involvement in women with deep infiltrating endometriosis: analysis of a large series.

In women with deeply infiltrating endometriosis (DIE) what is the prevalence of involvement of endometriotic tissue and fibrosis in ureteral endometriosis (UE), as assessed by histological staining? In women with DIE, ureteral involvement is more often due to endometriotic tissue rather than fibrosis. In the current literature, histological evaluation of ureteral endometriosis is mainly based on the degree of wall infiltration by endometriosis instead of the tissue composition. A few studies reported ill-defined and contradictory histological data on the tissue composition of UE. Retrospective observational study based on clinical records of women affected by DIE, laparoscopically treated for UE at a tertiary referral center, between January 2010 and March 2013. All cases of ureteral nodule excision or ureterectomy with histological examination of the specimens were included. Exclusion criteria were other identified causes of hydroureteronephrosis, medical therapy for a period of at least 3 months before surgery and previous surgery for DIE. A total of 77 patients were included in the study and among them seven (9%) presented with bilateral ureteral involvement, giving a total of 84 cases of UE available for analysis. All patients had stage IV endometriosis. According, respectively, to the presence of endometrial glands and/or stroma cells or of fibrotic tissue only, the endometriotic UE and fibrotic UE groups were compared with regard to hydroureteronephrosis at pre-operative urinary tract computerized tomography scan, type of surgical procedure performed to treat UE (nodule removal or ureterectomy), association with other locations of the disease and post-operative complications (ureteral fistula or stenosis). For the 84 cases of UE, 65 (77%) and 19 (23%), respectively, showed endometriotic tissue and fibrotic tissue only. Presence of hydroureteronephrosis and endometriotic pattern of UE showed a significant association [endometriotic UE 44/65 (68%) versus fibrotic UE 8/19 (42%); P = 0.04]. Fibrotic pattern of UE and presence of concomitant recto-vaginal endometriosis showed a significant association [endometriotic group: 29/65 (45%) versus fibrotic group 18/19 (95%); P < 0.001]. The retrospective and monocentric (tertiary referral center) study design. Besides the distinction between extrinsic and intrinsic UE based on the degree of wall infiltration by endometriosis, a new classification according to the histological pattern of UE could be useful for clinicians, both in the diagnostic and therapeutic fields. None.

A Simplified Laparoscopic Approach to Repair Vesicovaginal Fistula: The M.S. Ramaiah Technique

To describe a simplified laparoscopic approach for the management of vesicovaginal fistula (VVF), with the specific aim of decreasing laparoscopic intracorporeal suturing and to highlight our results with this simplified approach. A retrospective chart review was carried out to all patients who underwent VVF repair at our institute by the "simplified laparoscopic approach" between January 2011 and August 2014. Preoperative evaluation consisted of intravenous urography, micturating cystography, and cystoscopy. Patients with malignant fistulas, history of pelvic irradiation, or co-existent ureteric fistulas were excluded. The procedure consisted of an initial cystoscopy to intubate bilateral ureteric orifices with ureteric catheter, as well as the fistula with a ureteric catheter of different color. A 3-port technique was used. The simplified laparoscopic approach consisted of limited cystotomy, single-layer bladder closure with 3-0 V-Loc barbed suture and omental patch over the vaginal opening. A total of 22 patients were included in the analysis. Mean interval before surgery was 2.5 months. One patient had previous failed transvaginal repair. Transvaginal hysterectomy for benign uterine pathology constituted the predominant etiology of VVF in this series. Mean fistula size was 7 mm. Mean operative time was 75 minutes. All patients were continent at catheter removal at postoperative day 14 and remained symptom free in the follow-up period. The simplified laparoscopic approach of VVF repair produces excellent results with minimal morbidity.

Place de la robotique dans l’endométriose pelvienne profonde : à propos du registre de la SERGS

ObjectivesTo assess the interest of robotic-assisted laparoscopy in the context of deep infiltrating endometriosis and to investigate perioperative results. Patients and methodsFrom November 2008 to April 2012, 164 women with stage IV endometriosis who underwent robotic-assisted laparoscopy (DA VINCI Intuitive Surgical System®) were included by eight international participating clinical centers. Patients were divided in 4 groups according to the localization of the nodule(s): rectum (n=88), bladder (n=23), ureter and uterosacral ligaments (n=115) et hysterectomy (n=28). We evaluated the procedures performed, the duration of intervention, the complications, the recurrence and the impact on fertility. ResultsIn the rectum group, there was a laparotomy conversion, 2 sutured rectal injuries and a red cells blood transfusion. In the bladder group, there was a vesicovaginal hematoma and a prolongated intermittent self-catheterization. In the ureter and uterosacral ligaments group, there was 2 ureteral fistulas and there was no complication in the hysterectomy group. Discussion and conclusionThis study is the largest series published in the literature on robotic-assisted laparoscopy for deep infiltrating endometriosis. The interest of robotic-assisted laparoscopy in deep infiltrating endometriosis seems to be promising while no increase in surgical time, blood loss, and intra- and postoperative complications were observed.

Laparoscopy for ureteral endometriosis: surgical details, long-term follow-up, and fertility outcomes

To evaluate perioperative details, long-term outcomes, and postsurgical fertility in case of laparoscopic ureterolysis for deep endometriosis. Retrospective analysis of prospectively collected data. Academic research center. One hundred nine consecutive women who underwent laparoscopic ureterolysis for deep endometriosis. Laparoscopic excision of ureteral endometriosis (ureteral shaving was attempted in all cases). Perioperative details, long-term outcomes, fertility rates, and need for secondary surgery, stratifying on presence/absence of hydronephrosis. Predictors of longer operative time, pain recurrence, and fertility were also investigated. No conversion to open surgery was necessary. Intraoperative ureteral injury occurred in one case (0.9%). Nine women (8.3%) underwent ureteral stenting. Eight cases (7.3%) of mild postoperative complications were registered; no case of severe complications or postoperative ureteral fistula occurred. An increase was observed in the risk of short-/long-term adverse outcomes, according to the grade of preoperative hydronephrosis. Of the 80 women with available follow-up data, secondary ureteral procedures were necessary in 5 women (6.3%), whereas 22 patients (27.5%) had recurrence of endometriosis symptoms. Among the 36 women who wished to conceive, a total of 26 pregnancies were registered in 20 women (55.6%). The miscarriage rate was 15.6%. Hydronephrosis grade≥2 was independently associated with longer operative time and higher rate of symptoms recurrence. Adjuvant hormonal therapy after ureterolysis was the only independent factor associated with lower fertility rates. Laparoscopic ureterolysis is a safe procedure, with encouraging pregnancy rates and satisfactory long-term results. However, hydronephrosis grade≥2 is associated with worse outcomes.

Robot-assisted laparoscopy for deep infiltrating endometriosis: international multicentric retrospective study

This study aimed to assess the interest in robot-assisted laparoscopy for deep infiltrating endometriosis and to investigate the perioperative results. From November 2008 to April 2012, 164 women with stage 4 endometriosis who underwent robot-assisted laparoscopy (da Vinci Intuitive Surgical System) were included by to eight international participating clinical centers. This study evaluated the procedures performed, the duration of the intervention, the complications, the recurrence, and the impact on fertility. The average operative time was 180 min. The main complications were laparotomy (n = 1, 0.6%), sutured bowel injury (n = 2, 1.2%), transfusion for a 2,300-ml bleed (n = 1), prolonged urinary catheterization (n = 1, 0.6%), ureter-bladder anastomotic leak (n = 1, 0.6%), and ureteral fistula after ureterolysis (n = 2, 1.2%). The reoperation rate was 1.8% (n = 3). The mean follow-up period was 10.2 months. A full recovery was experienced by 86.7% (98/113) of the patients. After surgery, 41.2% (42/102) of the patients had a desire for pregnancy, and 28.2% (11/39) of them became pregnant. This study analyzed the largest series of robot-assisted laparoscopies for deep infiltrating endometriosis published in the literature. No increase in surgical time, blood loss, or intra- or postoperative complications was observed. The interest in robot-assisted laparoscopy for deep infiltrating endometriosis seems to be promising.

Clinical effects of pedicled omentum covering and wrapping the ureteral anastomosis to prevent ureteral anastomotic leakage after surgery of abdominal and pelvic tumors

To explore the clinical effects of pedicled omentum covering and wrapping the ureteral anastomosis to prevent ureteral anastomotic leakage after surgery of abdominal and pelvic tumors. Clinical data of 64 patients with ureteral anastomosis after surgery of abdominal and pelvic tumors treated in our department from May 2005 to May 2012 were retrospectively analyzed. They were assigned into 2 groups. There were 23 patients of ureteral anastomosis combined with pedicled omentum surrounding and wrapping the anastomotic site (optimization group), and 41 cases of ureteral anastomosis alone (control group). The clinical data of all the 64 patients were reviewed and the therapeutic effects of the two treatment approaches were compared. At one week after the operation, there were 8 cases (34.8%, 8/23) with ureteral anastomotic fistula in the optimization group and 31 cases (75.6%, 31/41) in the control group (P = 0.010). In the postoperative days 1-3, the average drainage everyday from abdominal tube around the anastomotic site was 260.4 ml and 320.8 ml, respectively (P = 0.446). The average drainage volume everyday was 80.5 ml and 160.5 ml from the postoperative day 4 to day 7 (P = 0.015). The average time of removal of the peritoneal cavity drainage tube was 18.5 d in the optimization group and 32.6 d postoperatively in the control group (P = 0.015). Covering and wrapping the ureteral anastomosis with pedicled omentum can promote the rapid adhesion of surrounding tissues to reduce urine leakage and postoperative complications, and shorten the surgical treatment cycle.

Ureteral perigraft fistula: a case report and review of the literature

Ureteral perigraft fistula: a case report and review of the literature

Lich-Gregoir Technique and Routine Use of Double J Catheter as the Best Combination to Avoid Urinary Complications in Kidney Transplantation

IntroductionUrinary complications in kidney transplantation cause patient morbidity and can decrease graft survival. Most of the complications stem from the vesicoureteric anastomosis. Different techniques for ureteroneocystostomy (UNC) have been designed to avoid these complications. The routine use of a double J catheter after the anastomosis has the same purpose. Our aim was to show our experience and compare the use or non-use of a double J catheter and different techniques for ureteric reimplantation with the rate of urologic complications. Material and MethodsWe conducted a retrospective, nonrandomized study of 1011 renal transplantations performed between July 1985 and April 2012. We recorded the surgical techniques for UNC, the use or non-use of a double J catheter, and urinary complications (ureteric fistulae and strictures). The first 700 kidney transplantations (group A) were performed using several UNC techniques (Taguchi, Leadbetter-Politano, and Lich-Gregoir) with a selective use of double J catheter according to the criteria of the surgeon. In the last 311 patients (group B), a surgical technique was established (Lich-Gregoir), as well as the universal use of double J catheters. ResultsUrinary fistula occurred in 7% of group A patients and 2% of group B patients (P = .0001). Ureteric stricture occurred in 5.3% of patients in group A and 3% of group B patients (P = .09). In our study, routine prophylactic stenting combined with the Lich-Gregoir UNC technique has decreased the incidence of postoperative fistulae. ConclusionsIndividually, the use of double J catheters seems to lessen the incidence of fistulae, although statistically, the difference is not significant. Accurate knowledge of the complications rates, recommendations of guidelines, and the early diagnosis are essential to attaining reasonable results in kidney transplantation.

Indian experience of robotics in gynecology.

AIMS:To study the role of robotics in various gynaecological cases, benign and malignant.MATERIALS AND METHODS:A total number of 80 cases have been analyzed. Operative time, estimated blood loss, hospital stay, complications, conversion rates have been retrospectively studied in all cases. Nodal yield, vaginal margin and paracervical clearance have been studied in all malignant cases. This investigation was conducted at a single minimal access surgery institute.RESULTS:Of total 80 cases, 29 were benign and 51 were malignant cases. In benign cases, total robotic hysterectomies were 24, 2 cases of tubotuboplasty, 1 case of endometriotic cyst excision, 1 case of metroplasty and 1 case of rectovaginal fistula. In 51 cases, 37 of radical hysterectomy, 9 exenterations and 6 were parametrectomy. In benign cases, mean operative time was 80 min, estimated blood loss was 20 ml, mean hospital stay was for 1 day, no major complications and no conversions. In malignant cases, mean operative time was 122 min, estimated blood loss was 50-100ml, 2 cases of ureteric fistulas and no conversions, nodal yield was 30, vaginal margin was 2.5-3.8 cm and para cervical clearance was 3-3.5 cm.CONCLUSIONS:Ours is the largest series of robotic surgery in gynecological procedures in India. Benign and malignant cases were addressed robotically showing the feasibility.

Ureteral Replacement and Onlay Repair with Reconfigured Intestinal Segments

Ureteral loss represents a surgical challenge to provide low pressure drainage while avoiding urinary stasis and reflux. The ideal replacement should optimize drainage while minimizing absorption, allowing for ureteral repair of varied lengths and locations with maximal preservation of the urinary tract. We reviewed our experience with ureteral repair, focusing on the use of reconfigured intestine. We report what is to our knowledge the novel use of reconfigured intestine as an onlay flap on the preserved ureteral segment and as a circumferential interpositioned segment. A total of 16 ureters were repaired in 4 men and 9 women using reconfigured ileum, colon or appendix. Mean patient age was 45 years (range 26 to 66). The etiology of the ureteral defect was iatrogenic in 8 patients, retroperitoneal fibrosis in 3, trauma in 3 and ureteritis cystica in 1. Mean defect length was 10 cm (range 5 to 20) in the 10 right and 6 left ureters, and the defect was proximal in 3, mid in 4, distal in 7 and panureteral in 2. Ureteral replacement was performed using a segment of ileum in 13 cases or colon in 1. The segment was detubularized and reconfigured according to the Yang-Monti principle and used as a complete retubularized interposed segment in 7 cases or as an onlay flap on the opened ureter without resection in 7. Also, 2 ureters were reconstructed with an incised appendiceal flap onlayed over the preserved ureteral plate. At a mean followup of 44 months (range 12 to 78) all patients underwent antegrade nephrostogram, followed by renal scan and upper tract imaging. All patients tolerated the procedure without initial bowel or urinary tract complications. In 1 patient who had received radiation a ureteral fistula developed to a blind Hartmann pouch at 9 months, requiring repair. Ultimately, cystectomy was done for irradiation cystitis (onlay group). Another patient with bilateral obstruction at presentation lost unilateral renal function during 5 years. Urinary drainage was achieved in all 14 remaining renal units with preservation of function, as shown on renal scan. Patients reported minor mucous production without renal colic or stone formation. Long ureteral defects require tissue replacement when bladder flaps do not suffice. Ureteral replacement can be achieved by reconfigured intestinal segments, which are readily mobilized and secured as interposed segments or as an onlay flap on the preserved ureter. A relatively short segment can be used to repair a lengthy defect along any segment of ureter, also allowing for nonrefluxing reimplantation.

E77 Our experience with metallic ureteric stents for treating ureteral strictures and fistulae

E77 Our experience with metallic ureteric stents for treating ureteral strictures and fistulae

Urological Complications After 134 Pediatric Kidney Transplants: A Single-center Study

The incidence of surgical complications after kidney transplantation has been reported to range from 1% to 33%. The aim of this work was to report surgical urological complications among our cohort of 134 pediatric kidney transplantations. Epidemiological and clinical data of all patients younger than 18 years transplanted between January 1984 and May 2012 were collected from our prospective database. Urologic complications and management are reported herein. One hundred twenty-four patients, including 44% females underwent 134 renal transplants. Median age at the time of the surgery was 13 years. Mean time of end-stage renal disease was 25 months. We identified 10 subjects (7.5%) with urological complications: 5 ureterovesical stenoses, 2 lymphoceles, and 3 lower ureteral fistulas. All of the renal allografts were obtained from cadaveric donors. Mean age of these patients at the time of transplantation was 13 years. Mean cold ischemia time was 1613 minutes. All the patients required surgical management. All patients with ureterovesical stenoses underwent ureteral reimplantation using a Boari flap; those with lymphoceles underwent open marsupialization; 2 with ureteral fistulas underwent reimplantation of the ureter, and the other patient's case required placement of a nephrostomy tube and an antegrade ureteral catheter. All patients were treated successfully. Mean follow-up time of cases with urological complications was 9.5 years. Currently, 60% has nonfunctioning allografts; the mean current glomerular filtration rate of the functioning renal allografts is 55 mL/min. Despite requiring surgical management, all patients were treated successfully. Prompt identification and treatment of any complication are critical for graft and patient survival.

Lymphography with Patent Blue for Identification of Lymphatic Fistula After Radical Hysterectomy

Background: Pelvic lymphatic fistulas are generally manifested as vaginal discharge. Few cases describe its clinical presentation as chylous ascites. Case: We present a case of a 27-year-old patient who developed ascites following radical hysterectomy. A catheter was inserted into the ureter and a suction drain was left in the abdominal cavity because a ureteral fistula was suspected. The patient presented with high-output drainage of non-urinary fluid. A lymphatic fistula was diagnosed. Medical treatment was performed initially, followed by surgical intervention. Conclusions: Adequate diagnosis and treatment of the lymphatic fistula may offer a good result, with the patient being completely cured. (J GYNECOL SURG 29:45)

A Case of Ureteral Fistula through the Intervertebral Space

A Case of Ureteral Fistula through the Intervertebral Space

Urological Complications after Renal Transplantation - Therapeutical Management

Aims: Urological complications can affect the outcome of kidney transplantations by increasing the morbidity and mortality, including the lost of the graft. The aim of this study is to determine the incidence of urological complications, occurring after renal transplantation, in our centre. Methods: A series of 796 consecutive renal transplantations were performed between 1st of January 2004 and 31st of December 2011 in our Institute with a male to female ratio of 1.77/1. The mean age of the recipients was 35.16 years old. Renal grafts were obtained in 594 cases (74.62%) from living-related and in 202 cases (25.38%) from cadaveric donors. In 494 cases (62.1%) we performed a modified Leadbetter-Politano technique and, in another 302 cases (37.9%) a Lich-Gregoire ureterocystoneostomy. The follow-up of these patients ranged from 1 to 78 months, with none lost to follow-up. In 683 (85.8%) cases transplantation was carried out into the right iliac fossa, and only 113 (14.2%) cases in left iliac fossa. A double J ureteral stent was occasionally placed. Indwelling Foley catheters were removed seven to nine days post transplant and ureteral stents at four weeks post transplantation. Results: The overall incidence of urological complications was 7.78% (62 cases). Ureteral leakage and ureteral stenosis, located at the site of the ureterovesical anastomosis were the most common. We recorded 25 ureteral stenosis (3.14%), 16 ureteral fistulas (2.01%), 13 lymphoceles (1.63%), three hematoma with ureteral obstruction (0.37%),two cases of renal lithiasis(0.25%) and three cases of obstruction due to clot formation (0.37%). For the patients with ureteral stenosis (25 cases) the most common method of surgical treatment was vesicoureteral re-anastomosis 17 cases (2.13%). In the other eight cases (1.01%), with short and distal stenosis were treated effectively by anterograde (via NST) or retrograde endourological approach, with double pigtail stenting. Ureteral leakage was the second major urological complication (16 cases). Ureteral stenting was performed in eight cases (1.01%) (patients with vesicoureteral anastomosis leakage, marginal ureteral necrosis), seven vesicoureteral re-anastomosis (0.87%) (vesicoureteral anastomosis leakage, ureteral necrosis) and one ureteropyelostomy (0.13%) using the ipsilateral native ureter (inadequate length of ureter). Peri-graft collection with extramural obstruction of the ureter was diagnosed by ultrasonography in 13 cases. Percutaneous drainage was successful in six cases (0.75%) and open surgical peritoneal fenestration was performed in the other seven cases (0.88%). Two patients (0.25%) developed renal lithiasis. The treatment was retrograde double pigtail ureteral stent insertion followed by ESWL. Three patients (0.37%) developed hematoma with secondary ureteral obstruction, solved by percutaneous drainage in one case (0.12%) and open surgical evacuation and drainage in other two cases (0.25%). For the cases of ureteral clot obstruction (3 cases, 0.37%), a double pigtail ureteral stent insertion after endourological clot removal was successful. Conclusions: Urological complications related to leakage or stenosis can be treated minimally invasive by ureteral stent insertion or by surgical vesicoureteral reimplantation. Early diagnosis and treatment will help maintain renal graft function. In our study, graft survival after successful treatment has been similar for all the patients.

A primary arterial–ureteral fistula after an aortic-bifemoral bypass

INTRODUCTIONPrimary arterial–ureteral fistula is a rare and diagnostically challenging condition which may present with massive hematuria. PRESENTATION OF CASEA case of primary arterial–ureteral fistula (AUF) is presented in a patient with a previous prosthetic aortic-bifemoral bypass. The AUF treated with arterial and ureteral resection, arterial ligation and ureteral reconstruction. DISCUSSIONPrimary AUF are more frequently associated with aneurysmal degeneration of the arterial wall. The development of a primary fistula due to an iliac artery aneurysm many years after an aortic-bifemoral bypass performed due to atherosclerotic obstructive disease is a very unusual presentation of this entity. Multiple surgical strategies can be employed in achieving hemorrhage and infection control, urinary tract continuity, and vascular reconstruction. CONCLUSIONA multidisciplinary approach and the achievement of a pre-operative diagnosis are essential for an effective management of this condition with prognostic implications.